Authors: Yngvild Olsen, MD, MPH1; Joshua M. Sharfstein, MD2
Follow-up Q and A Webinar: The Role of Shame in Opioid Use Disorders
This Q and A webinar further discussed Dr. Braun-Gabelman’s online module, “The Role of Shame in Opioid Use Disorders,” and allowed participants of the module to pose questions to Dr. Braun-Gabelman; she also presented a few cases related to this topic.
In this slide presentation, Dr. Matulich talks about the basic concepts of Motivational Interviewing (MI). After a brief definition, topics include: the Spirit of MI, the four basic OARS skills, and the “processes” of MI.
- Develop an understanding of the fundamental spirit and principles of motivational interviewing.
- Gain up-to-date information regarding the research and evidence of motivational interviewing.
- Develop an understanding of empathic counselling skills, central to using the technique.
- Learn when and how to use advice and other more directive elements of motivational interviewing.
- Observe elements of motivational interviewing, including how motivational interviewing can be used to roll with resistance, resolve ambivalence , encourage change and commitment talk, and help people carry through changes to health behaviors.
Alan Lyme, LCSW, ICADC, ICCS, MINT, is the Clinical Supervisor for the Screening, Brief Intervention, and Referral to Treatment (SBIRT) grant program at the Medical Center of Central Georgia. Mr. Lyme has provided trainings nationally on Motivational Interviewing, clinical supervision, and skills on working with men. He is a MINT (Motivational Interviewing Network of Trainers) recognized MI trainer, an Internationally Certified Clinical Supervisor, and an Internationally Certified Alcohol and Drug Counselor.
MI founder William Miller talks about how Motivational Interviewing helps people resolve their ambivalence about changing addictive behaviors. Watch the full video here.
Learn how Motivation Interviewing is applied to working with addictions in this video with Motivational Interviewing expert and trainer Cathy Cole, LCSW. Watch the full video here.
This video role-play is part of an online training for which EUs are available for re-credentialing CASACs and members of NASW. You can register for the training at the www.bestpracticetrainers.org website. In the role-play, the therapist is using Motivational Interviewing OARS skills with a client who is using marijuana.
- Health professionals are often trained in “motivational interviewing” (MI), a way of encouraging patients struggling with substance abuse to make positive changes in their lives. Family and friends of people struggling from opioid abuse can also use these simple methods of talking to their loved ones about making changes, seeking treatment, and staying on track for recovery.
- Some of the techniques of motivational interviewing (MI) may seem surprising at first. MI can be especially difficult when discussing a topic like opioid abuse that may be emotionally charged or cause conflict. Families and friends of opioid-addicted individuals may always seek help from trained substance abuse counselors. However, these MI guidelines can be a helpful and simple start in encouraging loved ones to make a change.
- Motivational interviewing is a way of discussing an issue that draws out an individual’s own reasons for changing, instead of relying on another person’s opinions or ideas. MI recognizes that ambivalence (having mixed feelings, or not being sure) about making a change is a common part of the recovery process. Discussing this ambivalence can help to bring out an individual’s personal reasons for making a change. MI focuses on finding and strengthening a person’s own motivation to change, in accordance with their own values, beliefs, concerns, and goals.
Principles of Motivational Interviewing
- Collaboration vs. Confrontation. MI encourages the idea of collaboration (working together to find a solution), instead of confrontation (arguing). One person is not the “expert” and the other is not the “student.” MI’s goal is mutual understanding, — not one person or the other being proven “right.”
- Drawing out vs. Forcing ideas about change. No matter how good another person’s ideas and reasons are, long-lasting change is more likely when a person discovers his or her own reasons for change. It is a common instinct to want to give a loved one advice and to try to “convince” them to change. However, this approach often results in more arguments than change. In MI, the interviewer’s goal is to “draw out” a person’s own motivations and skills for change, not to tell them what to do or why they should do it.
- Autonomy vs. Authority. The true power for change rests with the person dealing with opioid abuse, not in their friends, family, or doctor. Ultimately, it is up to the individual to make changes happen. In MI, the interviewer encourages the affected individual to take the lead in brainstorming ideas about how to achieve change.
- Roll with Resistance. This is one of the principles of MI that is hardest to follow. When discussing change, an opioid-dependent individual may often resist treatment suggestions and others’ ideas. In MI, the listener “rolls with” this resistance. The listener does not attempt to challenge or argue with the person who needs to change, since arguing often leads to the other person playing “devil’s advocate” — an ineffective situation. It is often our instinct to correct or advise a person struggling with change, and to try to solve the problem for them. However, it is often more effective to let the person come up with his or her own ideas for change. New points of view can be suggested for consideration, but shouldn’t be forced.
The basic principles of Motivational Interviewing are represented by the acronym OARS. Using each of these components help make the discussion more successful in encouraging change.
O Open-Ended Questions: Ask questions that can’t be answered with yes or no.
A Affirmations: Recognize and encourage a person’s strengths!
R Reflections: Respond in a way that makes it obvious that you’ve been listening carefully. The other person can then make corrections if they did not express themselves fully. This also allows the listener to express “empathy,” the ability to see the world through another’s eyes and share in their feelings and experiences. This can make the other person feel heard and understood.
Examples of reflections: “That must be difficult.” “I hear that you’re upset.” “It sounds like…” “What I hear you saying is…” “So on the one hand it sounds like… And, yet on the other hand…”
S Summaries: Summaries allow the listener to “recap” what has been discussed. The summary can highlight the other person’s strengths and reasons for change.
What Does a “Motivational Interview” Look Like?
Below are some examples of questions often used in MI. Successful discussions all look different, but these examples can be a useful starting point to help your loved one begin to think about change.
- Asking permission: Asking permission shows respect for the other person, and avoids the feeling of “lecturing.”
- “I’ve noticed that you’ve gotten into trouble a lot lately/ been having trouble with friends/[other problems]. Is it all right if we talk about your heroin/ prescription pain pill use?”
- Explore the persons’ reasons for change.
- Pros: “People usually use _____ because it benefits them in some way. What are the good things about _____? What do you like about _____?”
- Cons: “Can you tell me about the downsides? What are some aspects of using _____ that you’re not happy about? What are some things you wouldn’t miss?”
- Look back: Ask about a time before the person’s opioid addiction. “How were things better/ different?”
- Look forward: “What may happen if things continue as they are? What would be different if you went for treatment?”
- Ask for examples: “In what ways?” “Tell me more.” “What does that look like?” ”When was the last time that happened?”
- Explore Extremes: “What are the worst things that may happen if you keep using _____? What are the best things that might happen if you stop using _____?”
- Help a person find his or her motivation for change.
- Motivation for change comes from a person recognizing a “mismatch” between their current situation and where they want to be. A good listener can help their friend or family member to examine how their current situation and behavior conflicts with their own values and future goals.
- Explore life goals/ values. “What sorts of things are important to you? What sort of person would you like to be?” “If things worked out in the best possible way for you, what would you be doing a year from now?” (Support positive goals and values!) “How does opioid addiction fit in with these values?”
- Bring out discrepancies. “I hear that you have [goals, plans, values]. On the other hand, you’re telling me that heroin is causing [negatives]. “What would happen if you don’t change? What will your life be like if you stop?” “It sounds like when you stated using prescription pain meds there were many positives, but that now using them is causing you to lose friends and skip school. How would seeking treatment affect your life?”
- Reasons for change: “What makes you think you need to change? Why do you think I/others are concerned about _____?”
- Explore a person’s readiness for change.
- Scales of 1-10 can be helpful. “On a scale of 1 to 10, how important is it to you to quit, where 1 is not at all important and 10 is very important?” Ask why they did not give a higher or lower answer. “Why are you at a ‘6’ and not a ‘5’? Why not a ‘7’? What would it take to move from a ‘6’ to a ‘7’?
- Explore confidence/ fears. “How confident are you that you could cut down/ quit/ stay in treatment, if you decided to? Why?”
- Provide Summaries
- Summarize their choices and ambivalence (mixed feelings). “It sounds like you are concerned about heroin use because it is costing you a lot of money and causing family problems. You also said quitting will probably mean not hanging out with your best friends any more. That doesn’t sound like an easy choice.”
- Encourage a person to fall on the positive side of their ambivalence, by siding with the negative status quo. “Perhaps using [opiate drug] is so important to you that you won’t give it up, no matter the cost.”
- Ask about a decision.
- “You were saying that you were trying to decide whether to continue/ cut down/ go to treatment. If you decide to change, what would you have to do to make it happen?”
- “After talking about it, are you more clear about what you would like to do?”
- State Goals: If the person is ready, help them set goals.
- Good goals are SMART: Specific, Meaningful, Assessable (Measurable), Realistic, and Timed.
- “What will be your first step? What will you do in one or two days?”
- “Have you ever done any of these things before? What’s worked/ not worked in the past? Why?”
- “Who will be helping/ supporting you?”
- “On a scale of 1 to 10, what are the chances that this goal is possible for you?”
- Provide Affirmations: MI is a Strengths-Based Approach. MI tries to emphasize the other person’s strengths instead of weaknesses. Many people have tried to change before and failed, creating many doubt and fears. Listeners can help support and highlight an individual’s strengths and skills, to encourage the belief that change is possible.
- “It shows a lot of strength/courage/determination to…”
- Show Empathy: If the person isn’t ready to make a decision, empathize with their difficulty.
- “How can I help you get past some of these difficulties? Is there something else that could help you make a decision?”
- “What could you do to reduce some of these problems while you’re deciding what to do?”
[Link to MI Tri-Fold]
Sources for Motivational Interviewing
- “An Overview of Motivational Interviewing,” obtained from MotivationalInterview.org
- “An Example of an MI ‘Session’” from the work of WR Miller and S Rollnick
- Sobell & Sobell. (2008.) Motivational Interviewing Strategies and Techniques: Rationales and Examples
Myth #1: MAT replaces one addiction with another.
Sometimes patients and their families or friends wonder why doctors use drugs like buprenorphine or methadone to treat opioid addiction, since these medicines are in the same family as heroin and prescription opioid pain medication. However, physician-prescribed buprenorphine and methadone are not just “substituting” one addiction for another.
Addiction treatment uses longer-acting and safer medications to help overcome more dangerous opioid addictions. Many studies have shown that maintenance treatment with long-acting opioids like methadone or buprenorphine helps keep patients healthier, reduces criminal activity, and helps prevent drug-related diseases like HIV/AIDs and Hepatitis.
Patients who strongly object to using maintenance opioids for any reason may choose a different type of MAT. For example, naltrexone is not an opioid drug, and actually works by blocking the effects of opioids in the brain for up to one month. For more information, see the Community Resources section of PCSSMAT.org.
Myth #2: MAT is a bad moral choice. It is inferior to complete, unassisted abstinence.
Some of the negative stigma of MAT comes from different ways of understanding addiction.
Addiction as a moral and spiritual problem: Some people with opioid use disorder and their communities view addiction as a moral and spiritual failing, not as a medical disease. In this view, medical treatment with methadone may seem like a “crutch,” or a weak moral choice, because patient is continuing to use an opioid on a daily basis. Complete, unassisted abstinence is the most common treatment plan in this view of addiction. MAT’s ability to make addiction recovery easier and less painful may not be seen as a benefit, but may suggest that a patient “isn’t as serious” about quitting., MAT patients do not meet many 12-step programs’ definitions of abstinence because of their use of opioidmedications, and they may be excluded from these groups.However, individuals attending 12-step groups may be criticized as having “traded one drug for another” if they reveal that they are seeking treatment with buprenorphine or methadone. This is not always the case, and many AA and NA members understand the role of MAT in recovery.
Addiction as a medical disease: Instead of understanding addiction as only a moral or spiritual failing, many medical professionals have begun to view opioid addiction as a medical disease. The disease of addiction can be caused by repeated exposure to a drug, coupled with genetic or environmental risk factors, leading to physical changes in the brain’s opioid receptors. In this view, addiction can be treated and managed with medication, much like other medical diseases.
Myth #3: MAT is not effective because it does not immediately end drug dependence.
opioid use disorder or Addiction is not “cured” by the use of MAT. Addiction is a “chronic” (long-lasting) disease. Medical treatment for addiction can be comoared to medical treatment for other common chronic diseases like diabetes or high blood pressure. Just as diabetes is not “cured” by the use of insulin, and people with high blood pressure often continue taking medications for many years, so people with opioid addiction are not “cured” but instead well-managed by MAT.
Misconception #4: “I’ve known a few people who could stop using opioids without help from any kind of medication. MAT is only for the weak. “
Though opioid abuse may begin with a series of poor judgments, addiction involves real, physical changes in the brain. While some people are eventually able to quit using opioids on their own, the majority of patients go though many dangerous cycles of relapse and recovery. MAT can make the recovery process much safer, and has saved many lives by preventing death from overdose or dangerous behaviors associated with “street” drug use.
[Link to Myths and Misconceptions Trifold]
—Frank, D. (2011.) The trouble with morality: the effects of 12-step discourse on addicts’ decision-making. J Psychoactive Drugs 43(3), 245-256.
Why is there a negative stigma associated with Methadone?
Methadone is perceived by many as “substituting” one addiction for another. Methadone treatment is only provided in special addiction clinics, separated from the rest of healthcare, which may contribute to its stigma. This separation may also serve to distance methadone from the medical model of understanding addiction as an illness rather than as a moral failing.
Patients, their families, and their communities could benefit from greater acceptance of methadone treatment’s proven benefits in reducing illicit opioid use and its negative consequences. 
— Frank, D. (2011). “The trouble with morality: the effects of 12-step discourse on addicts’ decision-making.” J Psychoactive Drugs 43(3). 245-256.  Frank, D. (2011).  Etesam, F., Assarian, F., Hosseini, H., & Ghoreishi, F. S. (2014.) Stigma and its determinants among male drug dependents receiving methadone maintenance treatment. Arch Iran Med. Feb 17(2). 108-14.  PCSS-MAT.  Frank, D. (2011).
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People with substance use disorders and other mental health issues face greater stigma than those with other illnesses…..
This guide provides clinicians with questions to begin discussions with adult patients about mental illness, substance use disorders, or both. It includes resources for patients who need an evaluation after a positive screening.